Validity of the GLIM criteria for the diagnosis of malnutrition in patients with colorectal cancer: A multicenter study on the diagnostic performance of different indicators of reduced muscle mass and disease severity

OBJECTIVES

To assess the concurrent and predictive validity of different combinations of Global Leadership Initiative on Malnutrition (GLIM) criteria in patients with colorectal cancer considering different indicators of reduced muscle mass (MM) and the effects of the disease.

METHODS

A secondary analysis with patients with colorectal cancer. The reduced MM was assessed by arm muscle area, arm muscle circumference, calf circumference, fat-free mass index, skeletal muscle index (SMI) and skeletal muscle. Cancer diagnosis or disease staging (TNM) was considered for the etiologic criterion referred to as the effect of the disease. The other phenotypic and etiologic criteria were also evaluated, and we analyzed 13 GLIM combinations. Concurrent validity between GLIM criteria and Patient-Generated Subjective Global Assessment was evaluated. Logistic and Cox regression were used in the predictive validation.

RESULTS

For concurrent validity (n = 208), most GLIM combinations (n = 6; 54.5%) presented a moderate agreement with Patient-Generated Subjective Global Assessment and none showed satisfactory sensitivity and specificity (>80%). Reduced MM evaluated by SMI and SMI were present in the GLIM combinations associated with postoperative complications (odds ratio, ≥2.0), independent of other phenotypic and etiologic criteria. The combinations with reduced MM considering any method and fixed phenotypic criteria and TNM were associated with mortality (hazard ratio, ≥2.0).

CONCLUSIONS

Satisfactory concurrent validity was not verified. The GLIM diagnosis of malnutrition was associated with postoperative complications and mortality.

Nutritional management during critical illness in those with previous obesity surgery

PURPOSE OF REVIEW

The prevalence of overweight and obesity in our society is a pressing concern that has demanded immediate attention. Traditional treatments have proven ineffective for many individuals, leading to a surge in bariatric surgery as a last resort. While the rate of early and late postoperative complications may be low, when they occur, they place these patients at higher risk of requiring intensive care treatment. Therefore, it is our aim to discuss the nutritional care of these individuals.

RECENT FINDINGS

Nutritional management of critically ill postbariatric surgical patients is related to the difficulty of providing an adequate nutritional assessment, calculating the macro and micronutrient requirements, choosing the right therapy, and defining the timely moment to initiate it. The anatomic changes related to the bariatric operation pose a high risk for a nonfunctional gastrointestinal tract both in the early postoperative and late postoperative. Therefore, the route of nutrition will greatly rely on the absorptive capacity, as well as on the nutritional status, with parenteral nutrition being an early option, especially for those with high critical care severity scores. Also, these patients are known to have an altered microbiota which may influence the absorptive capacity. Immunonutrition, prebiotics, probiotics, and symbiotics may represent potential options, but there is currently little support for 'one size fits all'.

SUMMARY

The nutritional care of critically ill patients postbariatric surgery is a complex and nuanced process requiring a multifaceted precision approach. The distinct nutritional challenges of early and late postoperative patients necessitate a thorough nutritional assessment and a highly individualized nutritional care plan.

Comparison of pre- and posttransplant energy expenditure in patients undergoing hematopoietic stem cell transplantation and evaluation of associated factors

OBJECTIVES

Patients undergoing hematopoietic stem cell transplantation may present with metabolic alterations that can have an effect on their energy expenditure and nutritional status. This project aimed to compare the pre- and posttransplant energy expenditures of patients undergoing hematopoietic stem cell transplantation as well as related factors.

METHODS

This prospective study was conducted at a single center. Patients, undergoing autograft or allograft, were evaluated before transplantation and on the 10th and 17th d posttransplantation. Energy expenditure was measured by indirect calorimetry. Diet intake was assessed by a 24-h dietary recall. Infectious and noninfectious complications were analyzed between days 1 to 10 after transplantation and days 11 to 17 after transplantation. Paired model analyses were carried out to identify the pretransplantation and posttransplantation periods.

RESULTS

Twenty patients were evaluated with a mean age of 45.6 ± 17.2 y; a majority were male sex (65%), and the most frequent diagnoses were chronic myeloid leukemia (25%) and multiple myeloma (25%). Energy expenditure increased by 15% posttransplantation, and the energy requirement per kilogram of weight was 23 kcal/kg at day 10 after transplantation. Throughout the posttransplantation period, 45% of the patients required nutritional therapy. Negative energy and negative protein balance were observed at all analyzed times. Phase angle (P = 0.018), fever (P = 0.014), mucositis grades I to II (P = 0.018), and the total number of infectious and noninfectious events (P = 0.043) were associated with an increase in energy expenditure at day 10 after transplantation.

CONCLUSIONS

Energy expenditure increased after transplantation compared with pretransplantation in 50% of patients. Phase angle, fever, grades I to II mucositis, and infectious and noninfectious events were associated with increased energy expenditure at day 10 after transplantation.

Exploring the use of the GLIM criteria to diagnose malnutrition in cancer inpatients

OBJECTIVES

The Global Leadership Initiative on Malnutrition (GLIM) criteria establish a diagnosis of malnutrition based on the presence of at least one phenotypic and one etiologic criterion. This study aimed to assess the concurrent and predictive validity of the GLIM criteria in hospitalized cancer patients.

METHODS

This is an observational retrospective study, including 885 cancer patients, ages >18 y, admitted to a medical oncology inpatient unit between 2019 and 2020. All patients at risk for malnutrition according to the Nutritional Risk Screening 2002 score were assessed by the subjective global assessment (SGA) and 14 different combinations of the GLIM criteria. The SGA was considered the gold standard for assessing the concurrent validity of the GLIM combinations. For a subsample of patients with data available on inflammatory markers (n = 198), the serum albumin and C-reactive protein were included in the combinations as etiologic criteria. The predictive validity of the different combinations was tested using the occurrence of surgical complications as the clinical outcome. The sensitivity and specificity values were calculated to assess the concurrent validity, univariate and multivariate logistic regression models were used to test predictive validity. Adequate concurrent and predictive validity were determined as sensitivity and specificity values >80% and odds ratio values ≥2.0, respectively.

RESULTS

The median age of the patients was 61.0 y (interquartile range = 51.0-70.0). Head and neck cancer was the prevailing diagnosis and 375 patients were at nutritional risk. According to the SGA, 173 (26.1%) patients were malnourished (SGA categories B or C) and the prevalence of malnutrition ranged from 3.9% to 30.0%, according to the GLIM combinations. None of the tested combinations reached adequate concurrent validity; however, the presence of malnutrition according to four combinations independently predicted surgical complications.

CONCLUSIONS

The predictive validity of the GLIM was satisfactory in surgical cancer patients.

Global Leadership Initiative on Malnutrition criteria for the diagnosis of malnutrition and prediction of mortality in patients awaiting liver transplant: A validation study

OBJECTIVES

The Global Leadership Initiative on Malnutrition (GLIM) is a framework aiming to standardize malnutrition diagnosis. However, it still needs to be validated, in particular for patients with chronic liver disease. This study aimed to validate the GLIM criteria in patients with liver cirrhosis awaiting liver transplant (LTx).

METHODS

This was a retrospective observational study carried out with adult patients on the waiting list for LTx, consecutively evaluated between 2006 and 2021. The phenotypic criteria were unintentional weight loss, low body mass index, and reduced muscle mass (midarm muscle circumference [MAMC]). The etiologic criteria were high Model for End-Stage Liver Disease (MELD) and MELD adjusted for serum sodium (MELD-Na) scores, the Child-Pugh score, low serum albumin, and low food intake and/or assimilation. Forty-three GLIM combinations were tested. Sensitivity (SE), specificity (SP), positive and negative predictive values, and machine learning (ML) techniques were used. Survival analysis with Cox regression was carried out.

RESULTS

A total of 419 patients with advanced liver cirrhosis were included (median age, 52.0 y [46-59 y]; 69.2% male; 68.8% malnourished according to the Subjective Global Assessment [SGA]). The prevalence of malnutrition by the GLIM criteria ranged from 3.1% to 58.2%, and five combinations had SE or SP >80%. The MAMC as a phenotypic criterion with MELD and MELD-Na as etiologic criteria were predictors of mortality. The MAMC and the presence of any phenotypic criteria associated with liver disease parameters and low food intake or assimilation were associated with malnutrition prediction in ML analysis.

CONCLUSIONS

The MAMC and liver disease parameters were associated with malnutrition diagnosis by SGA and were also predictors of 1-y mortality in patients with liver cirrhosis awaiting LTx.

Canadian Nutrition Society Dialogue on disease-related malnutrition: a commentary from the 2022 Food For Health Workshop

This commentary represents a dialogue on key aspects of disease-related malnutrition (DRM) from leaders and experts from academia, health across disciplines, and several countries across the world. The dialogue illuminates the problem of DRM, what impact it has on outcomes, nutrition care as a human right, and practice, implementation, and policy approaches to address DRM. The dialogue allowed the germination of an idea to register a commitment through the Canadian Nutrition Society and the Canadian Malnutrition Task Force in the UN/WHO Decade of Action on Nutrition to advance policy-based approaches for DRM. This commitment was successfully registered in October 2022 and is entitled CAN DReaM (Creating Alliances Nationally for Policy in Disease-Related Malnutrition). This commitment details five goals that will be pursued in the Decade of Action on Nutrition. The intent of this commentary is to record the proceedings of the workshop as a stepping stone to establishing a policy-based approach to DRM that is relevant in Canada and abroad.

Findings from Positron Emission Tomography-Computed Tomography with 18F-Fluorodeoxyglucose Uncover a Potential Marker of Nutritional Status in Cancer Patients: A Cross-Sectional Pilot Study

BACKGROUND

Cancer patients often have altered nutritional status and periodically undergo imaging tests. We hypothesized that standard uptake values (SUV) by positron emission tomography-computed tomography (PET/CT) with 18 F-fluorodeoxyglucose (¹⁸F-FDG) could be associated with the nutritional status of cancer patients.

MATERIALS AND METHODS

Adult cancer patients who underwent clinical evaluation and PET/CT with ¹⁸F-FDG on the same day were included in a cross-sectional pilot study. The focus was on evaluating ¹⁸F-FDG findings with regard to nutritional status, with an emphasis on liver SUVmean and tumor SUVmax.

RESULTS

A total of 179 patients were evaluated. One hundred and three (57.5%) were classified as well-nourished, 54 (30.1%) as suspected/moderately malnourished, and 22 (12.2%) as severely malnourished. The median hepatic SUVmean was 2.29, with 1.87 corresponding to the 10th percentile. There was a significant difference between the severely malnourished (2.02) and well-nourished or suspected/moderately malnourished (2.36) patients. Severely malnourished patients were more likely to have a SUVmean < 1.87 (p = .035). The tumor SUVmax also was significantly higher in severely malnourished patients (p = .003).

CONCLUSION

Cancer patients with severe malnutrition have lower values of hepatic SUVmean and higher values of tumor SUVmax in PET/CT with ¹⁸F-FDG when compared to well-nourished patients.

COVID-19: Lessons on malnutrition, nutritional care and public health from the ESPEN-WHO Europe call for papers

With prolonged pandemic conditions, and emerging evidence but persisting low awareness of the importance of nutritional derangements, ESPEN has promoted in close collaboration with World Health Organization-Europe a call for papers on all aspects relating COVID-19 and nutrition as well as nutritional care, in the Society Journals Clinical Nutrition and Clinical Nutrition ESPEN. Although more COVID-related papers are being submitted and continue to be evaluated, ESPEN and WHO present the current editorial to summarize the many published findings supporting major interactions between nutritional status and COVID-19. These include 1) high risk of developing the disease and high risk of severe disease in the presence of pre-existing undernutrition (malnutrition) including micronutrient deficiencies; 2) high risk of developing malnutrition during the course of COVID-19, with substantial impact on long-term sequelae and risk of long COVID; 3) persons with obesity are also prone to develop or worsen malnutrition and its negative consequences during the course of COVID-19; 4) malnutrition screening and implementation of nutritional care may improve disease outcomes; 5) social and public health determinants contribute to the interaction between nutritional status and COVID-19, including negative impact of lockdown and social limitations on nutrition quality and nutritional status. We believe the evidence supports the need to consider COVID-19 as (also) a case of malnutrition-enhanced disease and disease-related malnutrition, with added risk for persons both with and without obesity. Similarities with many other disease conditions further support recommendations to implement standard nutritional screening and care in COVID-19 patients, and they underscore the relevance of appropriate nutritional and lifestyle prevention policies to limit infection risk and mitigate the negative health impact of acute pandemic bouts.

Cinnamon Infusion Reduces Satiety and Increases Energy Intake: A Randomized Crossover Trial

BACKGROUND/AIMS

This study aimed to evaluate the effects of the intake of a single dose of cinnamon infusion on energy metabolism, appetite responses and food intake in healthy individuals.

METHODS

This was an open randomized crossover clinical trial, with a minimum washout of seven days, which was conducted in which two standardized breakfasts were served randomly: one with cinnamon infusion (2g, Cinnamomum sp.) And one with water (control). The study included 21 healthy volunteers. Energy expenditure (EE), diet-induced thermogenesis (DIT), respiratory quotient (RQ), substrate oxidation and appetite responses were evaluated, as well as prospective food intake.

RESULTS

Ingestion of cinnamon infusion did not alter EE, DIT, RQ or substrate oxidation. The incremental area under the curve for hunger, satiety and desire to eat did not differ between the treatment with cinnamon infusion and water, however, there was a reduction in the feeling of satiety (p=0.021) compared to the control treatment. The energy consumption of the first meal after treatment was higher (p=0.05) in the treatment with cinnamon infusion than in the control treatment. Regarding macronutrients or food intake throughout the day, there was no difference between treatments.

CONCLUSIONS

Although it did not affect energy metabolism, consuming a single dose of cinnamon infusion promoted less feeling of satiety and increased energy intake in the first meal after treatment. The study protocol was registered at the Brazilian Clinical Trials Registry Platform (RBR-5ftg3z).

Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool

BACKGROUND & AIMS

Studies using the Global Leadership Initiative on Malnutrition (GLIM) criteria for patients with liver cirrhosis are limited. This study aimed to assess the impact of malnutrition according to the GLIM criteria on the outcomes of patients awaiting a liver transplant (LTx) and compare these criteria with Subjective Global Assessment (SGA).

METHODS

This retrospective observational study included adult patients awaiting LTx. Patient clinical data, nutritional status according to various tools including SGA, and resting energy expenditure were assessed. The distinct phenotypic and etiologic criteria provided 36 different GLIM combinations. The GLIM criteria and SGA were compared using the kappa coefficient. The variables associated with mortality before and after the LTx and with a longer length of stay (LOS) after LTx (≥18 days) were assessed by Cox regression and logistic regression analyses, respectively.

RESULTS

A total of 152 patients were included [median age 52.0 (interquartile range: 46.5-59.5) years; 66.4% men; 63.2% malnourished according to SGA]. The prevalence of malnutrition according to the GLIM criteria ranged from 0.7% to 30.9%. The majority of the GLIM combinations exhibited poor agreement with SGA. Independent predictors of mortality before and after LTx were presence of ascites or edema (p = 0.011; HR:2.58; CI95%:1.24-5.36), GLIM 32 (PA-phase angle + MELD) (p = 0.026; HR:2.08; CI95%:1.09-3.97), GLIM 33 (PA + MELD-Na≥12) (p = 0.018; HR:2.17; CI95%:1.14-4.13), and GLIM 34 (PA + Child-Pugh) (p = 0.043; HR:1.96; CI95%:1.02-3.77). Malnutrition according to GLIM 28 (handgrip strength + Child-Pugh) was independently associated with a longer LOS (p = 0.029; OR:7.21; CI95%:1.22-42.50).

CONCLUSION

The majority of GLIM combinations had poor agreement with SGA, and 4 of the 36 GLIM combinations were independently associated with adverse outcomes.

Bioelectrical impedance vector analysis in patients on the waiting list for liver transplant: Associated factors and prognostic effects

OBJECTIVES

The aim of this study was to assess patients on the waiting list for liver transplant (LTx) according to bioelectrical impedance vector analysis (BIVA), as well as to verify the association between the placement of the vectors on the graph with clinical outcomes and identify the predictors to vector placement in quadrant 4 (Q4; indicating more hydration and less cellularity).

METHODS

This was a retrospective observational study including 129 patients ≥20 y of age awaiting LTx. Patients' nutritional status was assessed by using different tools, including single-frequency bioelectrical impedance analysis and the Subjective Global Assessment (SGA). Clinical data were registered. The BIVA was evaluated by comparing the individual vectors plotted for all patients to the tolerance ellipses of 50%, 75%, and 95% of the reference healthy population. The quadrant of the vector for each patient was registered.

RESULTS

The majority of the vectors were placed in Q1 (n = 54; 41.9%) and Q4 (n = 39; 30.2%). The presence of ascites or edema (hazard ratio [HR], 2.43; 95% confidence interval [CI], 1.15-5.12; P = 0.019) and the BIVA vector placed in Q4 in any ellipse (HR, 2.10; 95% CI, 1.07-4.09; P = 0.029) were independent predictors for mortality on the waiting list or ≤1 y after LTx. BIVA was not associated with longer hospital length of stay. The predictors of vector placement in Q4 were higher age, malnutrition according to SGA, and presence of ascites or edema.

CONCLUSION

Patients on the waiting list for LTx with BIVA vectors placed in Q4, in the 50%, 75%, or 95% tolerance ellipses, presented a worse prognosis.

SHORT-TERM EFFECT OF WHEY PROTEIN SUPPLEMENTATION ON THE QUALITY OF LIFE OF PATIENTS WAITING FOR LIVER TRANSPLANTATION: A DOUBLE BLINDED RANDOMIZED CLINICAL TRIAL

Background:

Chronic liver disease is associated with malnutrition that negatively impacts a patient’s health-related quality of life (HRQoL).

Aim:

To evaluate the short-term effect of whey protein supplementation on the HRQoL and nutritional and functional status of patients waiting for liver transplantation.

Methods:

This was a double-blind randomized clinical trial with patients waiting for liver transplantation who were randomized into two groups: WP (whey protein supplementation) and the control (casein supplementation). Both groups received 40 g (20 g in the morning and 20 g in the evening) for 15 days. Nutritional and functional status were evaluated. Energy balance was calculated as the difference between energy intake (24-hour recall) and total energy expenditure (assessed by indirect calorimetry). The chronic liver disease questionnaire was used to assess HRQoL. All measurements were performed before and after the intervention.

Results:

Fifty-six patients were evaluated. Malnutrition was present in 56.9%, and it was directly associated with a poor HRQoL (p<0.05). No improvement on the nutritional and functional status was observed, in either group after protein supplementation. HRQoL improved after WP and casein supplementation, with no differences between groups (p>0.05). Patients who met protein requirements and had a positive energy balance demonstrated a higher HRQoL score (4.9, p<0.05), without between-group differences.

Conclusion:

Malnutrition substantially reduces HRQoL. Short-term WP or casein supplementation improved similarly the HRQoL.

Hibiscus sabdariffa tea affects diet-induced thermogenesis and subjective satiety responses in healthy men, but not in women: a randomized crossover trial

The aim of this study was to investigate the effect of Hibiscus sabdariffa tea on energy expenditure, satiety response and food intake. This is an open-label, crossover, randomized clinical trial (RBR-5HZ86T), including 21 subjects (11 women, 10 men). The individuals were evaluated at acute moments (fasting and after eating standardized breakfast accompanied by water or Hibiscus sabdariffa tea). Resting energy expenditure was measured by indirect calorimetry, subjective satiety responses were evaluated with a visual analogue scale and food intake was assessed by using food records. The volunteers who drank the Hibiscus sabdariffa tea had lower perception of hunger (p=0.002) and greater feeling of satiety (p=0.010) and fullness (p=0.009) compared to control. Men who ingested the Hibiscus sabdariffa tea had an increase in nitrogen energy expenditure (water: 1501±290.7kcal, Hibiscus sabdariffa tea: 1619±288.9kcal; p=0.029). In comparison to control, men presented less perception of hunger (p=0.003) and desire to eat (p=0.016), increased satiety (p=0.021) and fullness (p=0.010), and women oxidized more fat (p=0.034) when they drank Hibiscus sabdariffa tea. There was no difference between treatments regarding the energy and macronutrient intake from the first meal and throughout the day (p>0.050) for all participants. The Hibiscus sabdariffa tea only affected energy expenditure and satiety responses in men. Clinical trial registry: ReBEC Platform of the Brazilian Clinical Trials Registry - RBR-5HZ86T Novelty bullets • Hibiscus sabdariffa tea promoted an increase in energy expenditure and caused less perception of hunger/desire to eat in men. • Hibiscus sabdariffa tea intake increased postprandial fat oxidation in women.

Nutrition competencies for undergraduate medical education: Results of an international interdisciplinary consensus

BACKGROUND

The gap between the nutrition education provided to medical students and the nutrition competencies and attitudes needed for physicians to provide adequate nutrition care is a global concern. There is no universally accepted benchmark on nutrition competencies for doctors. The objective of this study was to establish, by expert consensus, the objectives of undergraduate nutrition medial education, the nutrition core competencies, and strategies for curriculum development in medical nutrition education.

METHODS

We administered a Delphi survey to systematically gather the opinion of a panel of Latin American experts in nutrition. The survey questionnaire was constructed considering scientific literature by using a 5-point Likert scale. Consensus was defined as >70% agreement on the importance of an item (Likert scale 4 and 5).

RESULTS

A four-round Delphi survey was conducted for this research. In the second, third, and fourth rounds, we validated a total of 130 competencies by consensus, which were distributed into four different thematic areas: (1) basic nutrition concepts, (2) public nutrition and nutrition prevention throughout the life cycle, (3) nutrition status and disease, and (4) nutrition care process.

CONCLUSION

The curricula for general physician education in medical school must include health promotion, prevention, and treatment of diseases related to nutrition. This goal can be reached by integrating ≤130 competencies into four different fundamental areas.

Critical analysis of factors affecting the efficiency of nutrition therapy teams

BACKGROUND

Nutrition therapy (NT), defined as the provision of oral, enteral, or parenteral nutrition, should be considered a part of the holistic approach to patient care, while quality assessment of its practices is crucial. The present study aimed to identify variables capable of explaining the reason behind compliance of NTTs with the regulatory requirements.

METHODS

A cross-sectional study focused on assessing the quality of nutritional therapy practices among NTTs who previously stated to be able to comply with requirements of the Brazilian law versus those who were not able to meet these demands. Hospitals were classified as A (teams that had previously reported to be able to meet the requirements) and B (those unable to comply with them). The study was approved by the ethics committees of all participant institutions.

RESULTS

Twenty six hospitals met the inclusion criteria. The main hospital features, such as size, classification, service type, and percentage of hospitals providing NT were similar. Hospitals differed on the median number of patients undergoing NT per week: in group B (41.0; IR = 28.0-58.0) and group A (11.0; IR = 5.0-48.0) (p < 0.05), but there were no differences regarding personnel expertise. Both hospital groups had low quality control of the NT processes.

CONCLUSION

Lack of quality assurance is responsible for the inadequate services in both type of institutions.

Clinical Nutrition and Human Rights. An International Position Paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Acute effects of dry extract of ginger on energy expenditure in eutrophic women: A randomized clinical trial

BACKGROUND & AIMS

The thermic effect of food (TEF) is one of the components of total energy expenditure (TEE). Some bioactive compounds present in food could be useful to increase TEE. In this context, ginger has been extensively used as a thermogenic food despite no clear effect has been demonstrated yet. Herein, we evaluated the acute thermogenic effect of gingerol, a bioactive compound present in ginger, in healthy women.

METHODS

We carried out a randomized double-masked, cross-over and placebo-controlled clinical trial with 20 healthy eutrophic women. Anthropometric, body composition, indirect calorimetry and clinical variables were collected at baseline and throughout the intervention phase. A standardized breakfast was offered together with two dry extract of ginger capsules (5% gingerol) or a placebo (cellulose). Indirect calorimetry, blood pressure, heart rate, axillary temperature and blood collection were assessed at baseline and thereafter, at 30, 60, 120, 180 and 240 min postprandial. The analyses were repeated with a minimum of seven days' washout period.

RESULTS

Ginger intake did not increase the TEF of a standardized breakfast compared to the placebo. Oxygen consumption, respiratory quotient, blood pressure, heart rate, axillary temperature and metabolic profile were not different as well.

CONCLUSIONS

Our data show that gingerol did not modify the acute TEF in healthy women. More studies in human subjects, using different concentrations of gingerol, administration methods and intervention type (chronic effect) are necessary to clarify the putative thermogenic effect of ginger. Registered at ClinicalTrials.gov (Thermogenic Effect of Ginger - NCT03089593).

ACERTO Project - 15 years changing perioperative care in Brazil

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Nutrition Therapy Cost‐Effectiveness Model Indicating How Nutrition May Contribute to the Efficiency and Financial Sustainability of the Health Systems

Background

Method

Results

Conclusion

Ultrasonography and Other Nutrition Assessment Methods to Monitor the Nutrition Status of Critically Ill Patients

BACKGROUND

This study aims to evaluate the use of ultrasonography (US) as an instrument to assess the quadriceps muscles in patients admitted to intensive care units (ICUs), comparing the evolution of US-assessed mass muscle to other nutrition methods.

METHODS

We conducted a prospective observational study of adult patients aged ≥18 years admitted to an ICU of the Hospital das Clínicas in Brazil. Quadriceps muscle measurements were performed by US, and adductor pollicis muscle thickness and arm, calf, and thigh circumferences were measured at admission and every 2 days within the first week. Nutrition status was assessed at baseline by using the Subjective Global Assessment and the Global Leadership Initiative on Malnutrition criteria. Mechanical ventilation time, length of hospital and ICU stay, and mortality were recorded.

RESULTS

Sixty patients were included. Reductions in quadriceps thickness and rectus femoris cross-sectional area were observed at landmarks two-thirds reduction of both measurements from days 1 and 3 to days 5 and 7 (P = .017 and P = .000, respectively). The mid arm circumference (MAC) was reduced. Malnourished patients had lower initial muscle mass. However, muscle mass loss was similar between nourished and malnourished individuals (P > .005). Clinical outcomes were not impacted by muscle loss.

CONCLUSIONS

US muscle mass assessment was able to detect short-term changes in critically ill patients but must be used with caution. MAC was also identified as a useful follow-up tool.

The history of quality and safety of the surgical patient: from the initial standards to the present day

There are currently various concepts related to quality, which have been implemented by many hospitals and other healthcare institutions. The search for continuous improvement, the implementation of a quality culture and hospital accreditation have also been common, in these institutions. However, the history of hospital audits and accreditation is complex and full of dynamic concepts. The American College of Surgeons was pioneer in publishing, more than a century ago, the first document pertaining quality standards. After that, various programs and concepts have been developed and remodeled by distinct entities. In this article, we briefly review the history of quality in the world and Brazil. We also discuss related concepts regarding its assessment in healthcare.

Effect of Oral Nutrition Supplements and TGF-β2 on Nutrition and Inflammatory Patterns in Patients With Active Crohn's Disease

BACKGROUND

Crohn's disease (CD) is often associated with nutrition disorders. Many nutrition therapeutic alternatives have been studied. Nevertheless, the actual role of nutrition therapy is still controversial. The objective of this study was to assess the effects of nutrition supplementation with and without transforming growth factor-beta 2 (TGF-β2) on inflammatory, endoscopic, histopathologic, and nutrition parameters in active CD.

MATERIALS AND METHODS

Thirty-eight patients were allocated into 3 groups: group 1 (patients who received only nutrition orientation), group 2 (nutrition orientation and a normoproteic, normocaloric nutrition supplement), and group 3 (nutrition orientation and the nutritional supplement with TGF-β2). Clinical and nutrition evaluation, C-reactive protein (CRP) levels, and assessment of endoscopic and histologic parameters in the intestinal mucosa were performed before and after nutrition intervention.

RESULTS

The mean follow-up period was 3 months. In the beginning of the study, groups were homogeneous regarding age, gender, CD behavior and localization, and medication in use. In the end of the study, the Clinical Disease Activity Index score was reduced in groups 2 and 3; in group 3, a reduction in CRP levels and an improvement in histologic findings were observed. Among patients who received nutritional supplement, some anthropometric patterns were improved.

CONCLUSION

The results of the study indicate that nutritional supplementation improved nutrition and inflammatory patterns in patients with active CD. However, only patients receiving TGF-β2-enriched formula showed improvement in histologic parameters and significant reduction in CRP levels.

Association of food cravings with weight gain, overweight, and obesity in patients after liver transplantation

OBJECTIVE

After liver transplantation (LTx), patients often gain weight and many become overweight or obese; however, the association between LTx and food craving (FC) is unknown. The aim of this study was to describe FC among patients after LTx and verify its association with weight gain and obesity.

METHODS

This was a cross-sectional study that assessed 301 patients who underwent LTx (55.1 ± 12.7 y of age; time since LTx 6.6 ± 4.4 y; 64.1% men). Pregnant or nursing women were excluded. Patients were interviewed once either in the outpatient clinic or by completing the online questionnaire, from August 2016 to February 2017.

RESULTS

The median weight variation after Ltx was 8 kg (ranging from -16 to +41 kg). At evaluation, 62.5% (n = 188) of the patients presented excessive weight and 22.3% (n = 67) presented with obesity. The average score on the Food Craving Questionnaire-State (FCQ-S) was 33.4 ± 9 and for the Food Craving Questionnaire-Trait (FCQ-T) the median score was 68 (39-163). The FCQ-T dimensions of lack of control, preoccupation, emotion, environmental triggers/stimuli, and guilt correlated positively with weight gain (P < 0.05). The desire dimension on the FCQ-S was significantly associated with overweight in post-LTx patients (P < 0.05) and the FCQ-T dimensions [negative reinforcement (P = 0.013), lack of control (P = 0.016), emotion (P = 0.009), environmental triggers/stimuli (P = 0.029), and guilt (P = 0.007)] were associated with obesity.

CONCLUSION

Lack of control, preoccupation, emotion, trigger, and guilt were positively correlated with weight gain. Desire was significantly associated with overweight. Negative reinforcement, lack of control, emotion, environmental triggers/stimuli, and guilt were associated with obesity.

Safety and quality in surgery: surgeons' perception in Brazil

OBJECTIVE

to evaluate the perception of surgeons, members of the Brazilian College of Surgeons (CBC), on safety and quality issues in surgery, based on projects of Brazilian Ministry of Health (MS), CBC, World Health Organization (WHO), and American College of Surgeons (ACS).

METHODS

a questionnaire based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members, using Survey Monkey, in March 2018.

RESULTS

out of 7,100 members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform general surgery, 88.9% indicated knowing the project called Safe Surgery developed by MS, 73.1%, the CBC manual, and 14.6%, the ACS Strong for Surgery. Among those who indicated knowing the MS project, 73.1% said that they were accustomed to use it as a routine, and, among those who indicated knowing the CBC manual, 46.2% said that they were accustomed to use it. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, being failures related to surgical material (49.7%) and presence of foreign bodies (8.2%) the most common ones. There were distinct opinions on who was responsible for checking over the checklist.

CONCLUSION

the importance of safety and quality in surgery is well known by surgeons, but the practice is varied. Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits.

Fístulas Digestivas

Fístulas digestivas são comunicações anormais entre  qualquer parte do trato gastrointestinal e outro órgão  interno ou a pele. Podem causar desequilíbrio hidroeletrolítico, déficits nutricionais, formação de  abscesso, infecção, sepse ou sangramentos. Existem várias maneiras de se classificar uma fístula gastrointestinal de acordo com sua anatomia, débito,  tempo de aparecimento, etiologia, entre outros. Os fatores de risco associados ao surgimento de fístulas digestivas são muitos e ainda em descoberta, sejam eles  locais ou sistêmicos. Sua fisiopatologia é complexa e as complicações de maior morbidade e mortalidade estão relacionadas à desnutrição e infecção. O tratamento deve ser multidisciplinar e adaptado a cada caso,  envolvendo medidas nutricionais, antimicrobianos, cuidados com a pele e, por vezes, cirurgia. Como o cirurgião desempenha papel fundamental na prevenção e tratamento das fístulas digestivas, este artigo pretende fazer revisão de conceitos fundamentais sobre o tema,  discutindo classificação, etiologia, fisiopatologia, complicações, diagnóstico e principais aspectos no manejo clínico, nutricional e cirúrgico.

Relationship between Sarcopenia and mTOR Pathway in Patients with Colorectal Cancer: Preliminary Report

Sarcopenia is a syndrome characterized by loss of muscle mass and strength that impacts clinical outcomes and mortality in cancer patients. Although the molecular pathways involved in sarcopenia are not fully elucidated, the decrease in protein synthesis rate appears to be one of the most important events. The objective of this study was to investigate the relationship between sarcopenia and mTOR signaling pathway in patients undergoing colorectal resection surgery. Three groups of patients were assessed: 1) the control group (no cancer, no sarcopenia), 2) the cancer non-sarcopenic group and 3) the cancer sarcopenic group. All individuals were evaluated in relation to presence of sarcopenia and mTOR signaling pathway. Sarcopenia was evaluated by the combination of low muscle mass and low muscle strength, measured using computerized tomography images, and hand grip strength, respectively. Rectus abdominis muscle biopsy was performed at the time of surgery. mTOR pathway was analyzed by MILLIPLEX Map Kit Phospho/total mTOR 2-Plex Magnetic Bead Panel. Results were presented by phosphor/total mTOR ratio. Independent T test, Kruskal-Wallis test, and Dunn-Bonferroni post hoc were performed for statistical analysis and P < 0.05 was considered. Thirty-six patients and five controls were evaluated. A total of 13 cancer patients (36.1%) had sarcopenia. The phospho/total mTOR ratio was different between the control group (0.167 MFI) and the cancer non-sarcopenic group (0.055 MFI) (P = 0.026) as well as between the control group (0.167 MFI) and the cancer sarcopenic group (0.0049 MFI) (P = 0.041). No difference was observed on the median phospho/total mTOR ratio between the cancer groups (P > 0.05). More research is needed to extrapolate these results.

Factors preventing restoration of bowel continuity in patients with rectal cancer submitted to anterior rectal resection and protective ileostomy

OBJECTIVE

to evaluate the factors associated with non-closure of protective ileostomy after anterior resection of the rectum with total mesorectum excision for rectal cancer, the morbidity associated with the closure of ileostomies and the rate of permanent ileostomy in patients with rectal adenocarcinoma.

METHODS

we conducted a retrospective study with 174 consecutive patients diagnosed with rectal tumors, of whom 92 underwent anterior resection of the rectum with coloanal or colorectal anastomosis and protective ileostomy, with curative intent. We carried out a multivariate analysis to determine the factors associated with definite permanence of the stoma, as well as studied the morbidity of patients who underwent bowel continuity restoration.

RESULTS

In the 84-month follow-up period, 54 of the 92 patients evaluated (58.7%) had the ileostomy closed and 38 (41.3%) remained with the stoma. Among the 62 patients who had the ileostomy closed, 11 (17.7%) presented some type of postoperative complication: three had ileal anastomosis dehiscence, five had intestinal obstruction, two had surgical wound infection, and one, pneumonia. Eight of these patients required a new stoma.

CONCLUSION

according to the multivariate analysis, the factors associated with stoma permanence were anastomotic fistula, presence of metastases and closure of the ileostomy during chemotherapy.

Economic burden of hospital malnutrition and the cost-benefit of supplemental parenteral nutrition in critically ill patients in Latin America

AIM

Disease-related malnutrition (DRM) is a prevalent condition that significantly increases the risk of adverse outcomes in hospitalized patients, particularly those with critical illness. Limited data is available on the economic burden of DRM and the cost-benefit of nutrition therapy in high-risk populations in Latin America. The aims of the present study were to estimate the economic burden of DRM and evaluate the cost-benefit of supplemental parenteral nutrition (SPN) in critically ill patients who fail to receive adequate nutrient intake from enteral nutrition (EN) in Latin America.

METHODS

Country-specific cost and prevalence data from eight Latin American countries and clinical data from studies evaluating outcomes in patients with DRM were used to estimate the costs associated with DRM in public hospitals. A deterministic decision model based on clinical outcomes from a randomized controlled study and country-specific cost data were developed to examine the cost-benefit of administering SPN to critically ill adults who fail to reach ≥60% of the calculated energy target with EN.

RESULTS

The estimated annual economic burden of DRM in public hospitals in Latin America is $10.19 billion (range, $8.44 billion-$11.72 billion). Critically ill patients account for a disproportionate share of the costs, with a 6.5-fold higher average cost per patient compared with those in the ward ($5488.35 vs. $839.76). Model-derived estimates for clinical outcomes and resource utilization showed that administration of SPN to critically ill patients who fail to receive the targeted energy delivery with EN would result in an annual cost reduction of $10.2 million compared with continued administration of EN alone.

LIMITATIONS

The cost calculation was limited to the average daily cost of stay and antibiotic use. The costs associated with other common complications of DRM, such as prolonged duration of mechanical ventilation or more frequent readmission, are unknown.

CONCLUSIONS

DRM imposes a substantial economic burden on Latin American countries, with critically ill patients accounting for a disproportionate share of costs. Cost-benefit analysis suggests that both improved clinical outcomes and significant cost savings can be achieved through the adoption of SPN as a therapeutic strategy in critically ill patients who fail to receive adequate nutrient intake from EN.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

Nutrition Screening vs Nutrition Assessment: What's the Difference?

Screening and assessment imply different processes, with the former indicating risk factors for a deprived nutrition condition and the latter providing the nutrition diagnosis. Both should be routinely performed at hospital admission according to recommended guidelines; however, this is not the reality worldwide, and undernutrition remains highly prevalent in the hospital setting. Therefore, the objective of the current review is to delve into the principles leading to nutrition status deficiencies and how they should be addressed by screening and assessment. A critical appraisal for the reasons associated with the misunderstanding between screening and assessing is proposed without further discussing the many available screening tools while approaching some of the assessment instruments.